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1、应激性心肌病激性心肌病Stress Cardiomyopathy，SCDiagnosis, Pathophysiology,Management, and Prognosis武武汉亚洲心洲心脏病医院病医院徐承徐承义History1991年日本学者Dote等报道心理或躯体应激状态可以诱发一过性左心室功能不全，由于在收缩末期左心室造影呈底部圆隆、颈部狭小的图像，类似日本古代捉捕章鱼的篓子，而被命名为“Tako-tsudo”(章章鱼瘘瘘)心肌病心肌病1997年法国的心脏病学家Dominique Pavin报道了2例类似的病例，指出应激状态时儿茶酚胺水平升高和该病明显相关，并且提出了应激性心肌病激性心
2、肌病的概念2006年AHA关于心肌病的科学声明中，将其分类为一种独立的心肌病，正式命名为应激性心肌病DefinitionSC is a reversible cardiomyopathy,with a clinical presentation mimicking Acute coronary syndrome in the absence of significant coronary artery diseaseTako-tsubo cardiomyopathy, Apical Ballooning syndrome,and ampulla cardiomyopathyBroken Hea
3、rt syndrome，Transient Cardiac Ballooning syndrome应激性心肌病是应激因素诱发的类似急性冠脉综合征临床表现，伴有可逆性左室收缩功能障碍的一种临床综合征Mayo CriteriaTransient hypokinesis, akinesis, or dyskinesis in the left ventricle midsegments with or without apical involvement, regional wall motion abnormality extending beyond a single epicardial va
4、scular distribution, the presence of a stress trigger 左心室心尖和中部区域室壁运动短暂、超出单一血管供血范围的可逆性收缩功能丧失或异常，并存在应激因素Criteria proposed by the Mayo Clinic in 2004 and modified in 2008Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 冠脉造影示冠状动脉管狭窄程度50%，或无急性斑块破裂证据New electrograph
5、ic abnormalities and/or modest elevation in serum cardiac enzymes 新出现心电图异常或心肌酶学轻度升高Absence of pheochromocytoma or myocarditis 排除嗜铬细胞瘤、心肌炎All 4 criteria must be presentINCIDENCEThe incidence of SC is likely underrecognizedApproximately 1% to 2% of patients presenting with an initial diagnosis ACS act
6、ually have SC 发病率不明确，1%-2%的ACS患者实为SCUnderestimated for a variety of reasons：nonavailability of cardiac catheterization facilities in many regions the possibility for noncardiac presentationlack of a consensus of diagnostic criteria may contribute to misdiagnosisPRESENTATIONIt occurs most commonly in
7、 postmenopausal Women（90%）, mean age between 58 and 75 yrsSC seems to have an association with hypertension, COPD, and bronchial asthmaSC mimics ACS in most patients，acute substernal chest pain and dyspnea .shock, syncope, and cardiac arrest have been reported rarely2/3 of patients with emotional or
8、 physical stressECG FINDINGSST elevation in the precordial and diffuse T wave are the most common findings胸前导联ST段抬高及多导联T波倒置最为常见Differentiate SC from anterior STEMIPresence of ST segment depression in lead avR and absence of ST segment elevation in lead V1 identified SC with 91% sensitivity, 96% spec
9、ificity,and 95% predictive accuracyLABORATORY FINDINGSElevations in troponin and creatine kinase MB are typically mild Severe hemodynamic compromise is out of proportion and in contrast to the degree of cardiac enzyme elevationTroponin T levels ranged from 0.01 to 5.2 ng/mLCARDIAC CATHETERIZATION Co
10、ronary angiography Left ventriculographyA RAO end systolic leftventriculogram in typical variant (apical ballooning) of SC.B RAO end-diastolic ventriculogram in typical variant of SC.C RAO end-systolic left ventriculogram in atypical variant (basal ballooning) of SC. D RAO end-diastolic ventriculogr
11、am in atypical variant of SC.IMAGINGEchocardiographyventricular ballooning，wall motion abnormalities，decrease in EFNuclear Imagingusing Tc-99m，impairment of myocardial perfusionMagnetic Resonance Imagingpatients with SC do not show hyper-enhancement on delayed contrast enhancement MRIPATHOPHYSIOLOGY
12、The causal mechanisms remain uncertain 机制不明确 Stunned myocardium resulting from brief periods of ischemia owing to vasospasm is one possibility 心肌顿抑（冠脉痉挛引起短暂心肌缺血所致）是一种可能的机制Coronary microvascular dysfunction 冠状动脉微血管功能障碍 Increasing plasma levels of catecholamines 交感神经过度兴奋和血浆儿茶酚胺水平增高 Reduction in estrog
13、en levels following menopause 雌激素水平降低MANAGEMENTThe treatment of patients with SC is mainly supportive 目前尚无标准化的治疗方案,去除诱发因素很关键,加强对症支持治疗Patients with shock, cautious use of inotropic agents such as dobutamine and dopamine 谨慎使用受体兴奋剂以及多巴胺或多巴酚丁胺，必要时可考虑IABP支持It is reasonable to treat SC with -blocker, ACE
14、inhibitor and if pulmonary edema evelops,diuretics 受体阻滞剂、ACEI或ARB被推荐使用，受体阻滞剂可预防2.7%-8%的病人复发PROGNOSISSC has a favorable prognosis with in-hospital mortality 1%, with death more common in the setting of outflow obstructionThe 4-year recurrence rate of SC has been reported to be 11.4% ,but without any
15、significant difference in survival in an age and gender-matched population over the same duration SC长期预后相对较好, 避免情绪激动,在预防复发中非常重要Case Review王得清王得清，男，男/66岁， 住院号：住院号：654098主主诉：胸痛胸痛2天，天，晕厥一次厥一次现病史：病史：日日突突发胸痛，胸痛，位于下段胸骨后，位于下段胸骨后，压迫感，迫感，持持续约半小半小时好好转，于当地，于当地诊所所诊治治过程中突程中突发黑朦、黑朦、晕厥，数厥，数秒后意秒后意识恢复恢复。11.3日日14:00再
16、再发胸痛，性胸痛，性质同前，程度同前，程度较前前剧烈伴出汗，持烈伴出汗，持续不能不能缓解，解，当地医院当地医院诊断断 “AMI”，给予予药物治物治疗（ASA300mg ,波立波立维300mg,立普妥立普妥20mg）及杜冷丁肌注后好）及杜冷丁肌注后好转。既往史、个人史及家族史既往史、个人史及家族史无特殊。无特殊。入院入院查体：体：T 36.6，P 98bpm，R 20bpm，BP 140/80mmHg，肺部以及肺部以及查体无阳性体征；体无阳性体征；HR 104次次/分，分，律律绝对不不齐，S1强弱不等，弱不等，各瓣膜听各瓣膜听诊区未区未闻及及杂音音；双双下肢无水下肢无水肿院前院前辅助助检查：20
17、13年年11月月4日我院日我院ECG:1.心房心房颤动2.前前壁壁导联ST-T改改变。UCG:1.双房双房扩大大 室室间隔隔,左室前壁室壁左室前壁室壁运运动幅度减低幅度减低,三尖瓣三尖瓣轻度反流度反流, 左室收左室收缩功能稍减低功能稍减低,心包心包腔少量腔少量积液液 心律不心律不齐;2.先天性心先天性心脏病：房病：房间隔小缺隔小缺损（筛孔型，左向右分流）孔型，左向右分流）。cTnI 0.096ng/ml急急诊室室UCG入院入院诊断断冠状冠状动脉粥脉粥样硬化性心硬化性心脏病病 急性前壁心肌梗死急性前壁心肌梗死 心房心房颤动 心功能心功能I级（Killip分分级）监测ECG 1监测ECG 211.
18、0511.06监测cTnI冠脉冠脉CTALADLCXRCA应激因素激因素-SMA栓塞栓塞入院后治入院后治疗方案：方案：抗血小板聚集（阿司匹抗血小板聚集（阿司匹林林+波立波立维+替替罗非班）、抗凝非班）、抗凝病情病情变化：化：D2 解暗解暗红色血便色血便5次，上腹部次，上腹部压痛痛D3 解解暗暗红色血色血便便3次，次，诉腹痛伴出汗，腹痛伴出汗，查体腹肌体腹肌紧张，全，全腹腹压痛，痛，肠鸣音弱音弱腹部血管腹部血管CTA：SMA栓塞，栓塞，肠管缺血改管缺血改变腹部血管腹部血管CTA结论： SMA栓塞，栓塞，肠管缺血改管缺血改变下次预告下次预告Percutaneous Rheolytic Thrombectomy for Treatment of Acute SMA ThrombosisChengyi XU Xi SU
